The evidence backing the use of electrical stimulators for bone healing in patients fracture nonunions is growing. A 2015 study found that electrical stimulation was associated with a 35 percent reduction in nonunion development risk.[1]
Steven D. Steinlauf, MD, Miami-based Orthopaedic Associates of South Broward discusses the growing use of electric stimulation for bone healing and best practices for surgeons looking to add this technique to their practice.
Question: How is the use of electric stimulation for bone healing growing in the orthopedics field?
SS: Electric stimulation has been utilized to treat nonunion of long bones since the late 1970s. In the past, many physicians looked upon electrical stimulation devices as fancy machines without proven benefit. However, as the basic science and clinical literature have grown, a number of physicians have adopted the use of electrical stimulation to enhance bone healing. Not only do orthopedic surgeons and podiatrists use electrical stimulation to treat nonunions, but these devices may be used prophylactically to treat patients at high risk for poor bone healing. If further studies are performed confirming the clinical benefit of these devices, I feel that their use will increase in an effort to decrease the risk of nonunion and the associated morbidity and cost incurred when treating a nonunion.
Q: What is the evidence supporting the efficacy of electric stimulation for bone healing?
SS: The technology has been studied by numerous authors dating back to the original study by Fakuda and Yasuda in 1957. These authors discovered that mechanical stress on bone leads to the generation and piezoelectric potentials. In the 1960s, Brighton and others demonstrated that the application of small electric currents to bone stimulates osteogenesis. Over the ensuing decades, a number of authors have demonstrated that patients with established nonunions, which have failed multiple surgeries, can be successfully treated with the use of electrical stimulation.
Furthermore, a number of authors working with cell cultures and animal models have demonstrated that electrical stimulation leads to the upregulation of growth factors such as TGF-B, IGF-II and BMPs. Electrical stimulation has also been shown to enhance differentiation of mesenchymal stem cells, increase extracellular matrix production and stimulate endochondral ossification.[2]
Q: What are some advantages of using this technique for bone healing?
SS: There is clinical support for the use of electrical bone stimulation in the treatment of nonunions of long bones. Furthermore, there is support for the use of electrical stimulation as an adjunct to assist with healing of spinal fusions[3] and complex foot and ankle fusions.[4] The basic science points to improved bone formation with the use of electrical stimulation. Therefore, the potential for benefit is significant especially in the highest risk patients. These patients include those individuals with a tobacco addiction, multiple medical comorbidities such as diabetic neuropathy, avascular necrosis or multiple combined risk factors for poor healing. In all of these settings electrical stimulation provides a cost effective and, in many cases, a noninvasive, non-addictive method to help decrease the morbidity associated with poor bone healing, with minimal risk to the patient.
Q: What are some ways in which physicians can incorporate electric stimulation into their practice?
SS: Physicians need to understand that bone growth stimulators should not be utilized for all fractures, fusions or osteotomies. We must utilize our resources wisely and combine our knowledge of the science behind electrical stimulation with the appropriate indications in the appropriate patients. Patients who are poor candidates for revision surgery for a painful nonunion may very well benefit from electrical stimulation. In addition, patients undergoing high-risk fusions of the foot and ankle or of the spine likely will also benefit from electrical stimulation. Finally, with additional scientific support, I feel that we will likely discover that there will be a benefit in treating fresh, complex fractures in individuals at high risk for healing problems. Although the cost of the device is considered by many to be significant, the cost of a failed surgery both in dollars and in the form of loss of function is considerably more expensive.
Q: What are some best practices for dealing with the learning curve?
SS: When utilizing a bone growth stimulator in the treatment of nonunions, the orthopedic surgeon or podiatrist must explain to the patient that the device requires a minimum of three months to work dependent upon patient compliance. Therefore, abandoning the bone growth stimulator and opting for surgical intervention prior to three months would be inappropriate. Rather, it is prudent to follow up with the patient at six weeks and 12 weeks after initiating the bone growth stimulator to ensure that the fracture or arthrodesis site remains adequately aligned, the hardware remains in an adequate position and that the patient is doing well overall. If at three months there is progression of healing then the device is continued until the fracture, osteotomy or fusion heals completely. If, however, there is no evidence of healing whatsoever after three months, then the option of pursuing surgery can be entertained versus continuing with the stimulator for a longer period of time.
Disclaimer: The opinions and experiences presented here are for informational purposes only. Individual results may vary depending on a variety of patient-specific attributes and related factors.
Dr. Steinlauf is speaking on behalf of DJO Global and was reimbursed by the company for his time on this segment.
[1] Ilyas Aleem, MD, Idris Aleem, MSc, Nathan Evaniew, MD, Michael J. Yaszemski, MD, PhD, Thomas A. Einhorn, MD, Mohit Bhandari, MD, FRCSC, PhD. Efficacy of Electrical Stimulators for Bone Healing: A Meta-Analysis of Sham-Controlled Randomized Trials. Nature, 10.1038/srep31724, 2015.
[2] T. Bodamyali, B. Bhatt, FJ hughes, et. al. Pulsed electromagnetic fields simultaneously induce osteogenesis and upregulate transcription of bone morphogenic proteins. Biochemical and Biophysical Research Communications, 250:458-461, 1998.
[3] Raymond Linovitz, MD, Mini Pathria, MD, Mark Berhardt, MD, Daniel Green MD, et. al. Combined magnetic fields accelerate and increase spine fusion: A double-blind, randomized, placebo controlled study. Spine:27 (13), 1383-1388, 2002.
[4] SK Dhawan, SF Conti, NA Abidi, M Vogt. The effect of pulsed electromagnetic fields on hindfoot arthrodesis: a prospective study.Journal of Ankle and Foot Surgery: 43(2), 93-96, 2004.